<html lang="en"><head>
    <meta charset="utf-8">
    <title>留下您的足迹及疑惑</title>
        <meta name="viewport" content="width=device-width, initial-scale=1">
    <link href="http://cdn.bootcss.com/bootstrap/3.2.0/css/bootstrap.min.css" rel="stylesheet">
    <style type="text/css">      
.red{
    color:red;
    }
.form-area
{
text-align:center;
	}
.form-group{margin:10px;}
label{text-align:right;}
.col-md-5,.col-md-1,.col-md-4,.col-md-3{ width:64%;padding-left:2.5px;padding-right:2.5px;float:left;}
.col-md-1,.control-label{width:18%;}

.form-control{ border:1.5px solid #33CCFF;border-radius:15px;box-shadow:0 0px 0px rgba(0,0,0,.075) !important;-webkit-box-shadow:inset 0 0px 0px rgba(0,0,0,.075);}
    </style> 
    <script src="http://cdn.bootcss.com/jquery/1.11.1/jquery.min.js"></script>
    <script src="http://cdn.bootcss.com/bootstrap/3.2.0/js/bootstrap.min.js"></script>
</head>
<body>
<div class="container">
<div class="col-md-9">
    <div class="form-area">  
		<h3 style="margin-bottom: 25px; text-align: center;color:#33CCFF;">留下您的足迹及疑惑</h3>
		<p class="red">我们将在1个工作日内跟您联系，信息我们将严格保密。</p>
        <form action="/api/query" style="text-align:center;" method="post">
			<input type="hidden" name="_token" value='{{ csrf_token() }}'>
			<input type="hidden" name="uid" value='{{$uid}}'>
			<div class="form-group">
				<label for="tag" class="col-md-4 control-label">姓 名:</label>
				 <div class="col-md-4">
					<input type="text" class="form-control" id="name" name="name" placeholder="" required="">
				</div>
				<span class="red col-md-1">*</span>
			</div>
			<br style="clear:both">
			<div class="form-group">
				<label for="phone" class="col-md-4 control-label">手 机:</label>
				 <div class="col-md-4">
					<input type="number" class="form-control" id="phone" name="phone" placeholder="">
					
				</div><span class="red col-md-1">(选填)</span>
			</div>
			<br style="clear:both">
			<div class="form-group">
				<label for="wx" class="col-md-4 control-label">微 信:</label>
				 <div class="col-md-4">
					<input type="text" class="form-control" id="wx" name="wx" placeholder="">
					
				</div><span class="red col-md-1">(选填)</span>
			</div>
			<br style="clear:both">
			
			<div class="form-group">
				<label for="domain" class="col-md-4 control-label">域 名:</label>
				 <div class="col-md-4">
					<input type="text" class="form-control" id="domain" name="domain" placeholder="">
					
				</div><span class="red col-md-1">(选填)</span>
			</div>
			<br style="clear:both">
			<div class="form-group">
				<label for="suffix" class="col-md-4 control-label">访问路径:</label>
				 <div class="col-md-4">
					<input type="text" class="form-control" id="suffix" name="suffix" placeholder="">
					
				</div><span class="red col-md-1">(选填)</span>
			</div>
			<br style="clear:both">
			<div class="form-group">
				<label for="qq" class="col-md-4 control-label">Q Q:</label>
				 <div class="col-md-4">
					<input type="text" class="form-control" id="qq" name="qq" placeholder="">
					
				</div><span class="red col-md-1">(选填)</span>
			</div>
			<br style="clear:both">
			<div class="form-group">
				<label for="email" class="col-md-4 control-label">email:</label>
				 <div class="col-md-4">
					<input type="text" class="form-control" id="email" name="email" placeholder="">
					
				</div><span class="red col-md-1">(选填)</span>
			</div>
			<br style="clear:both">
			<div class="form-group">
				<label for="channel" class="col-md-4 control-label">渠 道:</label>
				 <div class="col-md-4">
					<input type="text" class="form-control" id="channel" name="channel" placeholder="">
					
				</div><span class="red col-md-1">(选填)</span>
			</div>
			<br style="clear:both">
			<div class="form-group">
				<label for="city" class="col-md-4 control-label">城 市:</label>
				 <div class="col-md-4">
					<input type="text" class="form-control" id="city" name="city" placeholder="">
					
				</div><span class="red col-md-1">(选填)</span>
			</div>
			<br style="clear:both">
			<div class="form-group">
				<label for="title" class="col-md-4 control-label">网页标题:</label>
				 <div class="col-md-4">
					<input type="text" class="form-control" id="title" name="title" placeholder="">
					
				</div><span class="red col-md-1">(选填)</span>
			</div>
			<br style="clear:both">
			<div class="form-group">
				<label for="nick" class="col-md-4 control-label">呢 称:</label>
				 <div class="col-md-4">
					<input type="text" class="form-control" id="nick" name="nick" placeholder="">
					
				</div><span class="red col-md-1">(选填)</span>
			</div>
			<br style="clear:both">
			<div class="form-group">
				<label for="nick" class="col-md-4 control-label">客服微信:</label>
				 <div class="col-md-4">
					<input type="text" class="form-control" id="nick" name="nick" placeholder="">
					
				</div><span class="red col-md-1">(选填)</span>
			</div>
			<br style="clear:both">
			
			
			<div class="form-group">
				<label for="query" class="col-md-4 control-label">疑 惑:</label>
				<div class="col-md-4" >
					<textarea class="form-control" id="query" name="query" placeholder="" ></textarea>                  
				</div><span class="red col-md-0"></span>
			</div>
			<br style="clear:both">
			<div class="form-group" style="border:0px;">
				<label for="query" style="border:0px;" class="col-md-4 control-label"></label>
				<div class="form-control col-md-4" style="border:0px;">
					<button type="submit" id="submit" name="submit" style="border:0px;background-color:#33CCFF;float:none;padding:0px;" class="btn btn-primary form-control">提交</button>                
				</div>
			</div>
        </form>
    </div>
</div>
</div>
</body></html>